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General Liability

Please fill out the form below. You may also fill out our short form by clicking here.

General Information
How did you hear about us? *
BIA Chamber of Commerce
Current Client Email
Google Yahoo
Mailer Yellow Pages
Referral: Website:
Other:  
Named Insured:
Contractor's License #:
Owner's Name:
Contact's Name:
Phone: *
 Fax:
Cell:
Email Address: *
 Preferred method of contact: *
Phone Fax Email Mail
Address Information
Mailing Address
Street: *
City: *
State: *
Zip: *
 
Premise Address
Street:
City:
State:
Zip:
Business Entity: *
Sole Proprietorship Partnership Corporation LLC Other:
Coverage
Desired limits of coverage:
$300,000 $500,000 $1,000,000 $2,000,000/1,000,000
Other
Other Desc:
Do you need an Excess Liability policy?
What limits?
Business Information:
Years of Experience:   Years in Business:
Number of Owners, Partners, Officers, Members:
Number active in Field:
 Describe in detail, the operations performed by you and your employees:
Estimated Gross Receipts Next 12 months:
Actual for last 12 months:
Employee payroll: (NOT including owners, officers, clerical or non-field employees)
Number of Full Time Employees:
Number of Part Time Employees:
Subcontractors:
Subcontractor Costs Next 12 months: % of gross receipts $ annually
Jobs Preformed by Subcontractors
Clean-up Concrete Drywall Excavation Electrical Framing
Finish Work Flooring Grading Glazier Landscape Painting
Plastering Plumbing Roofing Other
Type of Work Details:
Work Type Repair Remodel New Construction None
Condominiums:
Townhouses:
Apartments:
Tract Housing:
How many units will you work on at once?:
Work for Associations: Yes No
Percentage of Your Work:
Residential % Commercial: % Industrial: % Public Works: %
**New Construction: % Remodel Structural: % Remodel Service: %
Interior Work: % Exterior Work: %
General Contractor: Developer: % Artisan Contractor: %
(**) Is the New Construction Residential: Yes No
Past Largest Jobs
List your three largest jobs in the last three years
(MUST include start date/end date, project type, gross receipts, and description of work):
1)
2)
3)
Largest Future Incoming Jobs
List your three largest jobs in the last three years
(MUST include start date/end date, project type, gross receipts, and description of work):
1)
2)
3)
Losses or Claims
Have you had any losses or claims in the last five years? Yes No
If yes, provide details:
Special Certificate Wording
Do you have any special certificate wording or requirements?
If yes, provide details:    
Carriers Information
Worker's Compensation Carrier:
Expiration Date:
Commercial Auto Carrier:
Expiration Date:
Comments
Any additional information, comments or concerns?
If yes, provide details:    
Legal Terms
You MUST agree to our terms and conditions to submit this request by doing both of the following:
Print your Initials: *
Print Full Name: *
Please note that the information provided on this preliminary information form will assist us obtaining the best possible quote for you. The carrier may require an additional application or paperwork before offering/binding coverage. The quote provided may NOT offer all coverages as requested. See quote sheet for exclusions.
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Other Details
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